1104938455 NPI number — MS. JACQUELINE A AMMIRATA MD

Table of content: MS. JACQUELINE A AMMIRATA MD (NPI 1104938455)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104938455 NPI number — MS. JACQUELINE A AMMIRATA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AMMIRATA
Provider First Name:
JACQUELINE
Provider Middle Name:
A
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104938455
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
45 RESEARCH WAY STE 105
Provider Second Line Business Mailing Address:
UNIVERSITY ASSOCIATES OBGYN
Provider Business Mailing Address City Name:
EAST SETAUKET
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11733-6401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-672-8279
Provider Business Mailing Address Fax Number:
631-350-7200

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
320 MONTAUK HIGHWAY
Provider Second Line Business Practice Location Address:
SOUTH BAY OB GYN PC
Provider Business Practice Location Address City Name:
WEST ISLIP
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11795-4401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-587-2500
Provider Business Practice Location Address Fax Number:
631-587-0292
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  2060531 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01944912 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2507203 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 44G631 . This is a "BCBS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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